Medical History Form
North Dallas Dental Health
Patient Name
First Name
Last Name
Email Address
example@example.com
Age
Birth Date
-
Month
-
Day
Year
Date
Height and Weight
Marital Status
Please Select
Single
Married
Divorced
Widowed
Separated
Partner
Name of Spouse
First Name
Last Name
Spouse - Occupation
Spouse - Position
Spouse - Employer
Residence Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Position
Employer
Name of Party Responsible for Payment
First Name
Last Name
Relation to You
i.e. self, spouse, etc.
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referred by:
Please Select
Friend or Family Member
Referral from Physician
Google or Search Engine
Facebook
Other
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General Health
The following information is relevant to the treatment and procedures North Dallas Dental Health will recommend or provide for you. Please answer all questions to the best of your knowledge.
Name of Current Dentist or Practice Name
City of Current Dentist
How long have you regularly been visiting your dentist?
How frequently do you visit your dentist? (ex. every 6 months, annually)
Name of Previous Dentist
City of Previous Dentist
How long did you regularly visit your previous dentist?
How frequently did you visit your previous dentist? (ex. every 6 months, annually)
Are you currently under the care of a physician?
Yes
No
If so, why?
Physician's Name and/or Practice Name
How long have you visited your physician?
Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Last Complete Physical Exam
-
Month
-
Day
Year
if exact date is unknown, please estimate closest date
Purpose of Last Physical Exam
Ex. regular checkup, etc.
Findings from Last Physical Exam
Do you have any type of health problem?
Yes
No
If so, what?
Do you have any type of heart problem?
Yes
No
If so, what?
Do you have high or low blood pressure?
No, its normal
High Blood Pressure
Low Blood Pressure
Do you have shortness of breath after climbing one flight of stairs?
Yes
No
Do you bleed for more than 30 minutes after a minor cut or have any other minor bleeding problems?
Yes
No
If so, what?
Are you taking any medications or drugs including aspirin, vitamins, recreational drugs?
Yes
No
If so, list each drug, reason and who prescribed the drug:
Have you ever taken mediation for osteoperosis/osteopenia?
Yes
No
If so, what?
Have you been hospitalized in the past 10 years?
Yes
No
If so, for what?
Do you faint easily?
Yes
No
Have you taken cortisone or steroids in the past 6 months?
Yes
No
Have you been under the care of physicians in the past 2 years other than for a routine physical?
Yes
No
If so, for what?
Have you had any major illness or serious operation in the last 10 years?
Yes
No
If so, please describe:
Do you have any kidney or liver problems?
Yes
No
If so, please describe
Have you had rheumatic fever?
Yes
No
If so, when was it first diagnosed?
Do you have any type of articial valve, joint pin, prosthetic hip, etc., in place now?
Yes
No
Do you have a heart murmur, mitral valve prolapse or heart click?
Yes
No
Have you ever received psychiatric care or psychotherapy?
Yes
No
If so, which?
Have you ever tested positive for Tuberculosis?
Yes
No
Do you now or have you ever had Hepatitis?
Yes
No
If so, when?
Do you have AIDS or AIDS-Related Complex (ARC) or ever tested positive for the AIDS virus?
Yes
No
Please select each of the following medications to which you are allergic:
Acetaminophen
Aspirin
Carbocaine
Codeine
Demerol
Doxycycline
Duranest
Erythromycin
Halcion
Iodine
Keflex/Keflin
Latex
Morphine
Novacaine
Penicillin
Percodan
Phenaphen
Phenergan
Sulfa
Stadol
Tetracycline
Tylenol
Valium
Versed
Xylocaine
Other
Please list all other allergies
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Medical History
Your medical history is a significant factor in diagnosing and providing oral health care. Please answer the following questions to the best of your knowledge.
Do you have or have you ever had any of the following?
Rows
Yes
No
Anemia
Frequently swollen ankles
Stomach ulcers, diverticulitis, or ulcerative colitis
Excessive thirst or hunger over an extended period of time
The need to get up nightly to urinate
Cuts that tend to heal slowly
Diabetes
Hemophilia
Implant or transplant
Thyroid disturbance or taken thyroid tablets
Tuberculosis or emphysema
Kidney or bladder disease
Arthritis or rheumatism
Venereal disease (syphilis, gonorrhea, herpes II)
Epilepsy, convulsions or seizures
Cancer or radiation therapy
Glaucoma
Asthma, hay fever or eczema
Liver problems
Prostate problems (males only)
Do you smoke or use tobacco in any form?
Yes
No
If so, type and frequency?
Do you know that, if you smoke, you have more problems with gum diseases and their treatment?
Yes
No
Do you wear contact lenses?
Yes
No
Are you taking any sort of tranquilizers?
Yes
No
Are you taking anticoagulants (blood thinners)?
Yes
No
Are you taking antacids regularly?
Yes
No
If so, what?
Are you taking mood elevators?
Yes
No
Have you ever had Botox® or dermal fillers (e.g. Juvaderm®)?
Yes
No
Medical History (Females Only)
Have you or any of your blood relatives had heart disease or high blood pressure?
Yes
No
Have you or any of your blood relatives had diabetes?
Yes
No
Have you or any of your blood relatives lost teeth as a result of gum disease?
Yes
No
If so, who?
Have we treated any of your relatives?
Yes
No
If so, who?
Do you have any disease, medical condition, or health problem not listed above that you think we should know about or that you believe might affect treatment in any way? If so, please describe.
Do you have any questions before the examination? If so, what?
Patient's Signature (Or that of parent or guardian if patient is under 18 years of age)
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: